Take Home
Message: Athletes that do not
return to a cutting/landing sport reported lower scores on patient-reported
outcome measures; however, performed similarly on functional measures compared
with athletes that returned to sport post anterior cruciate ligament (ACL)
reconstruction. Hence, physical performance alone may be less than ideal for returning
an athlete to play post surgery.

An
anterior cruciate ligament (ACL) reconstruction is commonly used to help
patients regain function and return to sport. However, despite having good
function many patients fail to return to pre-injury levels of sport. It is
unclear if commonly used functional measurements may explain differences
between those who return to sport or not and if there may be other factors that
are important (for example, a patient’s perception of their knee function). To
bridge this gap the authors evaluated athletes that returned to sport (7 males,
11 females, ~23 years of age) and those that did not return (5 males, 7
females, ~26 years of age) to compare functional test scores and patient-reported
outcome scores between groups prior to surgery and at the time of the study. The patient-reported outcome measures were Tegner Activity Scale, Cartilage Injury Standard Evaluation From-2000, International Knee Documentation Committee Subjective Knee Evaluation Form [IKDC],
Marx Activity Scale, Knee Injury and Osteoarthritis Outcome Score [KOOS]). The functional tests were strength and
muscular endurance, Star Excursion Balance Test (SEBT), 3 single-legged hop tests, isokinetic
knee-flexor and knee extension strength, and a step-down-to-fatigue test. The
authors calculated a limb symmetry index based on a ratio of the mean
performance values for the functional performance tests from each leg. All
athletes had a history of primary unilateral ACL reconstruction (no difference
between surgery type between groups) and were at least 1 year post-operation (~4
years post). The authors defined return-to-sport as an athlete who returned to
at least 1 of the cutting or landing sports that they participated in before an
ACL injury. The authors found no differences between groups for limb symmetry
indexes, which typically exceeded 85% at the post-operative exam. The
non-return athletes reported lower scores on the IKDC and the symptoms portion
of the KOOS at the post-operative exam.

The
authors found that non-return athletes conveyed lower patient-reported outcome
measures despite performing similarly on the functional measures. Both groups
obtained functional limb symmetry index scores that exceeded 85% (the minimally clinically important difference). Hence, regardless of whether an athlete
returned to competitive sport or not within one year of an ACL reconstruction they
were likely to have restored physical performance. However, the non-return
group reported worse scores on patient-reported outcome measures, which exceeded
the minimally clinically important difference. This is important to note since
on average the assessment was 4 years’ post reconstruction; therefore, patient-reported
outcome measures may be more meaningful than physical measures for returning an
athlete to sport. Alternatively, there may be more effective ways to assess
function than with a limb symmetry index, which may overestimate the functional performance of an injured limb. It would be
interesting to see a longer follow-up (5-10 years down the line) and identify
risks of osteoarthritis because these patient-reported outcome measures could
be predictive of poor long-term outcomes. This information is helpful to ensure
we are properly restoring function without increasing risk of long-term
problems. Currently, medical professionals should use various functional and
sport-specific measures, as well as patient-reported outcomes to measure the
patient’s self-perceived physical function. This may help clinicians address
how an athlete feels they are doing and identify potential changes in
priorities or expectations in returning to sport.

Questions for Discussion:What criteria do you use to determine if an
athlete is ready to return to play after an ACL reconstruction? Do you use
patient-reported outcome measures?

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